Centers Plan for Nursing Home Care (HMO I-SNP)

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

• • In-Network: No

Diagnostic and Preventive Dental

• Dental X-Rays
  • In-Network: No Coins – No Copay
• Oral Exams
  • In-Network: No Coins – No Copay
• Prophylaxis (cleaning)
  • In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

• Diagnostic radiology services (e.g., MRI)
  • 20% coinsurance (Authorization Required)
• Outpatient x-rays
  • 20% coinsurance (Authorization Required)
• Lab services
  • 20% coinsurance (Authorization Required)
• Diagnostic tests and procedures
  • 20% coinsurance (Authorization Required)

Doctor visits

• Primary
  • $0 copay
• Specialist
  • 20% coinsurance per visit

Emergency care/Urgent care

• Urgent care
  • 20% coinsurance per visit (always covered)
• Emergency
  • 20% coinsurance per visit (always covered)

Foot care (podiatry services)

• Routine foot care
  • 20% coinsurance (Limits Apply)
• Foot exams and treatment
  • 20% coinsurance

Ground ambulance

• • 20% coinsurance

Health plan deductible

• • Coming soon

Hearing

• Fitting/evaluation
  • $0 copay (Limits Apply)
• Hearing aids
  • $0 copay (Limits Apply)
• Hearing aids OTC
  • Not covered
• Medicare-Covered Hearing Exam
  • $0 copay

Inpatient hospital coverage

• • Coming soon (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

• • $7,750 In-network

Medical equipment/supplies

• Diabetes supplies
  • 20% coinsurance per item
• Durable medical equipment (e.g., wheelchairs, oxygen)
  • 20% coinsurance per item (Authorization Required)
• Prosthetics (e.g., braces, artificial limbs)
  • 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

• Chemotherapy
  • 0-20% coinsurance (Authorization Required)
• Other Part B drugs
  • 0-20% coinsurance (Authorization Required)

Mental health services

• Outpatient group therapy visit with a psychiatrist
  • 20% coinsurance (Referral Required)
• Outpatient group therapy visit
  • 20% coinsurance
• Outpatient individual therapy visit
  • 20% coinsurance
• Inpatient hospital – psychiatric
  • Coming soon (Authorization Required)
• Outpatient individual therapy visit with a psychiatrist
  • 20% coinsurance (Referral Required)

Optional supplemental benefits

• • No

Other health plan deductibles?

• • In-Network: Yes

Outpatient hospital coverage

• • 20% coinsurance per visit (Authorization Required)

Preventive care

• • $0 copay

Rehabilitation services

• Occupational therapy visit
  • $0 copay
• Physical therapy and speech and language therapy visit
  • $0 copay

Skilled Nursing Facility

• • $0 copay

Transportation

• • $0 copay (Limits Apply, Authorization Required)

Vision

• Other
  • Not covered
• Contact lenses
  • Not covered
• Eyeglass frames
  • Not covered
• Routine eye exam
  • Not covered
• Upgrades
  • Not covered
• Eyeglass lenses
  • Not covered
• Eyeglasses (frames and lenses)
  • Not covered

Wellness programs (e.g., fitness, nursing hotline)

• • Covered